A novel approach to managing lateral elbow pain: An ultrasound-guided single-injection technique

INTRODUCTION

Pain in the lateral elbow is a frequently encountered issue in clinical practice, with lateral epicondylitis (commonly referred to as tennis elbow) being a primary cause. This condition is characterized by repetitive strain or overuse, leading to microtrauma and degeneration in the common extensor tendon (CET) origin [Figure 1]. The extensor carpi radialis brevis (ECRB) tendon is the most commonly affected, though other wrist extensors can also be involved. While the primary pathology involves these tendons, the condition can also impact adjacent structures, including the radial collateral ligament, lateral ulnar collateral ligament, and bone-tendon interface, which may contribute to persistent discomfort and impaired function in individuals with lateral epicondylitis.^[1]

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Figure 1:

Schematic showing coronal anatomy of the elbow.

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Pain relief injections are commonly utilized as a treatment option for lateral epicondylitis in individuals who continue to experience pain and difficulty performing daily activities despite undergoing standard conservative therapies, including physical rehabilitation, changes in activity levels, and the use of anti-inflammatory medications.^[2]

Corticosteroid injections are a widely recognized treatment option for managing lateral elbow pain, offering effective symptomatic relief by targeting inflammation and reducing pain at the affected site. Injections are typically administered both superficially and deep to the origin of the CET. An additional injection into the radiocapitellar joint is performed in patients with associated radiocapitellar degenerative change.^[3] Ultrasound guidance ensures more accurate and safe corticosteroid delivery, enhancing therapeutic outcomes.^[4-6]

Traditional methods for treating lateral epicondylitis and associated conditions often involve administering separate steroid injections: one targeting the extensor tendon origin using a lateral approach and another for the radiocapitellar joint through a posterior approach. While effective, this dual-injection strategy can increase procedural complexity and patient discomfort. This article outlines a novel single-injection technique under ultrasound guidance, offering a more efficient alternative by targeting both the extensor tendon origin and the radiocapitellar joint through a single entry point, improving patient comfort while maintaining treatment efficacy.

TECHNIQUE

The lateral elbow single-injection technique is practical and effective for addressing lateral elbow pain.

1. Patient positioning

   1. Position the patient in a seated or supine posture with the arm supported on a pillow or armrest for stability

   2. Flex the elbow to approximately 90°, ensuring the lateral aspect faces the operator for optimal access [Figure 2].

2. Preparation

   1. Perform an ultrasound scan using high (10–15 MHz) frequency probes to identify key landmarks, including the lateral epicondyle, ECRB tendon origin, and radiocapitellar joint space

   2. Mark the injection site and prepare it using standard aseptic techniques.

3. Injection procedure

   1. Administer a local anesthetic (1% lidocaine) into the subcutaneous tissues or use ethyl chloride spray to minimize discomfort

   2. Advance a 38 mm, 22-gauge needle under ultrasound guidance and inject a mixture containing 40 mg (1 mL) of depomedrone and 3 mL of 1% lidocaine into the radiocapitellar joint, and then reposition the needle and inject 2 mL of 1% lidocaine and 40 mg of depomedrone superficial to the CET [Figures 2 and 3]

   3. Utilize ultrasound to verify the distribution of the injectate within the radiocapitellar joint.

4. Post-procedure care

   1. Cover the injection site with a sterile dressing

   2. Advise the patient to rest the elbow for 24–48 h and gradually resume activities as tolerated

   3. Schedule a follow-up to monitor symptom resolution and address any adverse effects.

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Figure 2:

Schematic showing (A and B) Position of probe and patient, (C) injection into the radiocapitellar joint, (D) injectate within the radiocapitellar joint, (E) needle reposition superficial to the common extensor origin (CEO), and (F) showing injectate injected superficial to the CEO.

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Figure 3:

Longitudinal ultrasound (A) showing needle (red arrows) in the radiocapitellar joint and then (B) superficial to the common extensor origin. CEO: Common extensor origin.

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DISCUSSION

Ultrasound-guided lateral elbow single-injection technique offers several advantages over traditional dual-injection methods, which involve separate injections for the tendon and joint using different approaches. These traditional methods can be uncomfortable, time-consuming, and technically more challenging. The use of a single injection technique decreases the relative risk of infection in comparison to two different injections. In contrast, the lateral elbow single-injection technique is cost-effective and enhances both patient experience and treatment outcomes by targeting both the extensor tendon origin and the radiocapitellar joint through a single injection site.

By minimizing the number of needle insertions, this approach significantly reduces patient discomfort, which is especially beneficial for those who may experience anxiety or pain from multiple injections. In addition, the streamlined technique promotes faster recovery due to fewer interventions. Moreover, this technique effectively addresses the full range of pathology associated with lateral epicondylitis by targeting both the tendon and joint structures in a single procedure, effectively managing lateral elbow pain.

Concomitant lateral epicondylitis and radiocapitellar degenerative change is uncommon, but in patients who present with both conditions that need to be managed with injection, this technique may be used.

The use of ultrasound guidance plays a crucial role in the accuracy and safety of the technique. It allows the clinician to visualize the needle’s path in real-time, ensuring precise placement of the corticosteroid mixture while navigating complex anatomy. This precision minimizes the risk of injury to nearby structures, such as nerves and blood vessels, thus enhancing both the effectiveness of the treatment and patient safety.

Patients undergoing this technique often report higher satisfaction levels, owing to the reduced number of needle insertions and effective pain relief. Clinical outcomes are comparable to, or even exceed, those achieved with the traditional dual-injection approach, showing equal or superior results in terms of pain alleviation and functional improvement.

CONCLUSION

The lateral elbow single-injection technique presents a highly effective and patient-friendly alternative to traditional dual-injection treatments. By reducing patient discomfort, ensuring greater precision and safety, and providing equivalent or superior therapeutic outcomes, this method stands out as a preferred approach for managing lateral elbow pain associated with lateral epicondylitis and related conditions.